Deeply Infiltrating Endometriosis Lesions Research Articles

Imaging modalities for the non-invasive diagnosis of endometriosis.

Imaging modalities for the non-invasive diagnosis of endometriosis.

Protein oxidative stress markers in peritoneal fluids of women with deep infiltrating endometriosis are increased.

Are protein oxidative stress markers [thiols, advanced oxidation protein products (AOPP), protein carbonyls and nitrates/nitrites] in perioperative peritoneal fluid higher in women with histologically proven endometriosis when compared with endometriosis-free controls? Protein oxidative stress markers are significantly increased in peritoneal fluids from women with deep infiltrating endometriosis with intestinal involvement when compared with endometriosis-free controls. Endometriosis is a common gynaecologic condition characterized by an important inflammatory process. Various source of evidence support the role of oxidative stress in the development of endometriosis. We conducted a prospective laboratory study in a tertiary-care university hospital between January 2011 and December 2012, and included 235 non-pregnant women, younger than 42 year old, undergoing surgery for a benign gynaecological condition. After complete surgical exploration of the abdomino-pelvic cavity, 150 women with histologically proven endometriosis and 85 endometriosis-free controls women were enrolled. Women with endometriosis were staged according to a surgical classification in three different phenotypes of endometriosis: superficial peritoneal endometriosis (SUP), ovarian endometrioma (OMA) and deeply infiltrating endometriosis (DIE). Perioperative peritoneal fluids samples were obtained from all study participants. Thiols, AOPP, protein carbonyls and nitrates/nitrites were assayed in all peritoneal samples. Concentrations of peritoneal AOPP were significantly higher in endometriosis patients than in the control group (median, 128.9 µmol/l; range, 0.3-1180.1 versus median, 77.8 µmol/l; range, 0.8-616.1; P < 0.001). In a similar manner concentrations of peritoneal nitrates/nitrites were higher in endometriosis patients than in the control group (median, 24.8 µmol/l; range, 1.6-681.6 versus median, 18.5 µmol/l; range, 1.6-184.5; P < 0.05). According to the surgical classification, peritoneal fluids protein AOPP and nitrates/nitrites were significantly increased only in DIE samples when compared with controls (P < 0.001 and P < 0.05; respectively), whereas the others forms of endometriosis (SUP and OMA) showed non-statistically significant increases. We found positive correlations between peritoneal fluids AOPP concentrations, nitrites/nitrates levels and the total number of intestinal DIE lesions (r = 0.464; P < 0.001 and r = 0.366; P = 0.007; respectively). Inclusion of only surgical patients may constitute a possible selection bias. In fact, our control group involved women who underwent surgery for benign gynaecological conditions. This specificity of our control group may lead to biases stemming from the fact that some of these conditions, such as fibroids, ovarian cysts or tubal infertility, might be associated with altered peritoneal proteins oxidative stress markers. We demonstrate the existence of a significantly increased protein oxidative stress status in peritoneal fluid from women with endometriosis especially in cases of DIE with intestinal involvement. This study opens the way to future more mechanistics studies to determine the exact role of protein oxidative stress in the pathogenesis of endometriosis. Even if an association does not establish proof of cause and effect, these intrinsic biochemical characteristics of endometriosis may lead to the evaluation of therapeutic approaches targeting oxidative imbalance. No funding was used for this study. The authors have no conflict of interest.

Ultrasound mapping of pelvic endometriosis: does the location and number of lesions affect the diagnostic accuracy? a multicentre diagnostic accuracy study

BackgroundEndometriosis is a common condition which causes pain and reduced fertility. Treatment can be difficult, especially for severe disease, and an accurate preoperative assessment would greatly help in the managment of these patients. The objective of this study is to assess the accuracy of pre-operative transvaginal ultrasound scanning (TVS) in identifying the specific features of pelvic endometriosis and pelvic adhesions in comparison with laparoscopy.MethodsConsecutive women with clinically suspected or proven pelvic endometriosis, who were booked for laparoscopy, were invited to join the study. They all underwent a systematic transvaginal ultrasound examination in order to identify discrete endometriotic lesions and pelvic adhesions. The accuracy of ultrasound diagnosis was determined by comparing pre-operative ultrasound to laparoscopy findings.Results198 women who underwent preoperative TVS and laparoscopy were included in the final analysis. At laparoscopy 126/198 (63.6%) women had evidence of pelvic endometriosis. 28/126 (22.8%) of them had endometriosis in a single location whilst the remaining 98/126 (77.2%) had endometriosis in two or more locations. Positive likelihood ratios (LR+) for the ultrasound diagnosis of ovarian endometriomas, moderate or severe ovarian adhesions, pouch of Douglas adhesions, and bladder deeply infiltrating endometriosis (DIE), recto-sigmoid colon DIE, rectovaginal DIE, uterovesical fold DIE and uterosacral ligament DIE were >10, whilst for pelvic side wall DIE and any ovarian adhesions the + LH was 8.421 and 9.81 respectively.The negative likelihood ratio (LR-) was: <0.1 for bladder DIE; 0.1-0.2 for ovarian endometriomas, moderate or severe ovarian adhesions, and pouch of Douglas adhesions; 0.5-1 for rectovaginal, uterovesical fold, pelvic side wall and uterosacral ligament DIE. The accuracy of TVS for the diagnosis of both total number of endometriotic lesions and DIE lesions significantly improved with increasing total number of lesions.ConclusionsOur study has shown that the TVS diagnosis of endometriotic lesion is very specific and false positive results are rare. Negative findings are less reliable and women with significant symptoms may still benefit from further investigation even if TVS findings are normal. The accuracy of ultrasound diagnosis is significantly affected by the location and number of endometriotic lesions.

Magnetic resonance imaging features of vaginal endometriosis

Deeply infiltrating endometriosis (DIE) is defined by the presence of endometrial implants penetrating under the peritoneal surface or under the wall of the pelvic organs to a depth of at least 5 mm. This case report describes a case of DIE involving vaginal wall, periurethral tissue, torus uterinus and sigmoid wall. A 46-year-old female was presented with pelvic pain and deep dyspareunia which started six years ago, after a spontaneous interruption of pregnancy and uterine curettage. The pelvic magnetic resonance imaging (MRI) showed multiple DIE lesions localized in the vaginal wall mainly in the lower third of the vagina, between the anterior vaginal wall and the urethra, on the contour of the urethra and between the torus uterinus and the sigmoid wall. After MRI, laparoscopic biopsies confirmed the DIE lesions. According to the implantion theory, we assume that in our case the vaginal endometriosis was the result of implantation of endometrial glands into the vaginal tearing during the surgical procedure of curettage. In the current literature no author has so far described a diffuse involvement of the vaginal wall in the presence of uterine curettage after interruption of pregnancy. In our case, the anterior (peri-urethral tissue), middle (vaginal wall) and posterior (torus uterinus and bowel wall) compartments are involved. We can presume that the vaginal DIE is an early lesion, while the others lesions arise from vaginal walls by a contiguous extension. On MRI with endovaginal gel these lesions were more evident rather than without gel. MRI with gel allows us to give essential preoperative mapping for the surgical removal of the DIE lesions.

Clinical prediction of deeply infiltrating endometriosis before surgery: is it feasible? A review of the literature.

Background. Endometriosis is a chronic benign gynecologic disease that can cause pelvic pain and infertility affecting almost 10% of reproductive-age women. Deeply infiltrating endometriosis (DIE) is a specific entity responsible for painful symptoms which are related to the anatomic location of the lesions. Definitive diagnosis requires surgery, and histological confirmation is advisable. The aim of this paper is to review the current literature regarding the possibility of diagnosing DIE accurately before surgery. Despite its low sensitivity and specificity, vaginal examination and evaluation of specific symptoms should not be completely omitted as a basic diagnostic tool in detecting endometriosis and planning further therapeutic interventions. Recently, transvaginal ultrasound (TVUS) has been reported as an excellent tool to diagnose DIE lesions in different locations (rectovaginal septum, retrocervical and paracervical areas, rectum and sigmoid, and vesical wall) with good accuracy. Conclusion. There are neither sufficiently sensitive and specific signs and symptoms nor diagnostic tests for the clinical diagnosis of DIE, resulting in a great delay between onset of symptoms and diagnosis. Digital examination, in addition to TVS, may help to gain better understanding of the anatomical extent and dimension of DIE which is of crucial importance in defining the best surgical approach.

Laparoscopic Nerve-Sparing Radical Excision for Deeply Infiltrating Endometriosis (DIE) Lesions

Laparoscopic resection for posterior DIE (deeply infiltrating endometriosis) lesions is frequently difficult and time-consuming, and sometimes, will result in serious post-operative complications. One of the complications is post-operative bladder dysfunction. Patient may suffer from loss of bladder fullness sensation, or voiding difficulty. The main reason is the nerve injury during the radical excision for bilateral USL (uterosacral ligament) DIE lesions. In this video, we will demonste the important pelvic neuroanatomy landmarks, and the technique of nerve-sparing radical excision, focusing on the radicality, and the careful preservation of pelvic nerves.

Serum and peritoneal interleukin-33 levels are elevated in deeply infiltrating endometriosis

Interleukin 33 (IL-33) is a cytokine involved in fibrotic disorders. We have analyzed IL-33 levels in the sera and peritoneal fluids of women with various forms of endometriosis and investigated the correlation with disease activity. We conducted a prospective laboratory study in a tertiary-care university hospital between January 2005 and December 2010. Five hundred and ten women with histologically proven endometriosis and 132 endometriosis-free controls were enrolled in this study. Complete surgical exploration of the abdominopelvic cavity was performed in each patient. Blood samples and peritoneal fluids were obtained before and during surgical procedures, respectively. IL-33 was measured by an enzyme-linked immunosorbent assay in sera and peritoneal fluids, and the concentrations correlated with the extent and the severity of endometriotic lesions. IL-33 was detectable in 23.1% of serum samples from all 642 women studied and 75.0% of peritoneal fluid samples studied (44 women with endometriosis and 36 controls). Serum IL-33 was higher in deeply infiltrating endometriosis (DIE) (median, 104.9 pg/ml; range, 8.0-104.9) than in endometriosis-free women (median, 61.3 pg/ml; range, 7.5-526.0; P = 0.022) or in women affected by superficial endometriosis (median, 36.8 pg/ml; range, 7.5-179.0; P < 0.001). Peritoneal IL-33 was higher in DIE than in endometriosis-free women (median, 642.0 pg/ml; range, 25.9-3350.6 versus median, 194.2 pg/ml; range, 12.7-1818.2, respectively; P = 0.003). We found positive correlations between serum IL-33 concentration and intensity of dysmenorrhea (r = 0.174; P = 0.028) and gastrointestinal symptoms (r = 0.199; P = 0.027), total number of DIE lesions (r = 0.224; P = 0.016) and the worst DIE lesion (r = 0.299; P < 0.001). In spite of the number of samples with undetectable levels, serum IL-33 is abnormally elevated in women with endometriosis and principally in DIE. Elevated serum IL-33 is correlated with the intensity of preoperative painful symptoms, and with the extent and severity of the DIE. IL-33 may be considered as a novel cytokine involved in the pathogenesis of DIE.

Transvaginal US after Bowel Preparation for Deeply Infiltrating Endometriosis: Protocol, Imaging Appearances, and Laparoscopic Correlation

Deeply infiltrating endometriosis (DIE) is a common gynecologic disease that is characterized by a difficult and delayed diagnosis. Radiologic mapping of the DIE lesion sites is crucial for case management, patient counseling, and surgical planning. Transvaginal ultrasonography (US) is the initial imaging modality for investigating DIE and has been the focus of several recent studies. DIE typically manifests at imaging as hypoechogenic nodules throughout the affected sites and thickening of the intestinal wall, with some lesions showing a mixed pattern due to cystic areas. Transvaginal US performed after bowel preparation improves the ability to diagnose intestinal lesions and provides invaluable details, including which layers of the intestine are affected and the distance between the lesion and the anal border. It is vital that radiologists be familiar with the technical aspects of this modality and with the US manifestations of DIE lesions. Transvaginal US performed after bowel preparation should be the first-line imaging modality for the evaluation of women with suspected endometriosis.

Difficult Total Laparoscpoic Hysterectomy (TLH) for a Case with Double Uterus, Double Cervix and Double Vagina, with Severe Pelvic Endometriosis with Diffuse Pelvic Adhesion, with Previous Hemi-Subtotal Hysterectomy

Study Objective: Introduction: Total laparoscopic hysterectomy (TLH) for cases with Mullerian anomalies usually possess particular surgical difficulties. Congenital adhesion bands among bladder, rectum, and Mullerian duct may obscure the usual dissection plane. Concomitant deeply infiltrating endometriosis (DIE) will be another problem. For patient with previous incomplete surgical procedures, the situation becomes even worse. (distorted anatomy). Materials & Methods: The 42 y/o lady had Mullerian anomaly. (didelpyis uterus, double cervix, double vagina) She even received open LSO, and Lt subtotal hysterectomy. This time, severe adenomyosis (on Rt uterus), and posterior DIE were noted. Results: Total laparoscopic intervention (TLH+ adhesiolysis + radical excision of DIE lesions) was successfully performed, after complete development of bilateral retroperitoneal spaces, medial pararectal spaces and rectovaginal space. The double vagina lumens were clearly visible through laparoscopic view during the procedure. Conclusion: For patient with Mullerian anomaly associated with advanced endometriosis and severe pelvic adhesion, laparoscopic approach is feasible. Study Objective: Introduction: Total laparoscopic hysterectomy (TLH) for cases with Mullerian anomalies usually possess particular surgical difficulties. Congenital adhesion bands among bladder, rectum, and Mullerian duct may obscure the usual dissection plane. Concomitant deeply infiltrating endometriosis (DIE) will be another problem. For patient with previous incomplete surgical procedures, the situation becomes even worse. (distorted anatomy). Materials & Methods: The 42 y/o lady had Mullerian anomaly. (didelpyis uterus, double cervix, double vagina) She even received open LSO, and Lt subtotal hysterectomy. This time, severe adenomyosis (on Rt uterus), and posterior DIE were noted. Results: Total laparoscopic intervention (TLH+ adhesiolysis + radical excision of DIE lesions) was successfully performed, after complete development of bilateral retroperitoneal spaces, medial pararectal spaces and rectovaginal space. The double vagina lumens were clearly visible through laparoscopic view during the procedure. Conclusion: For patient with Mullerian anomaly associated with advanced endometriosis and severe pelvic adhesion, laparoscopic approach is feasible.

Severe ureteral endometriosis: the intrinsic type is not so rare after complete surgical exeresis of deep endometriotic lesions

To evaluate the rate of intrinsic ureteral endometriosis in patients presenting with severe ureteral endometriosis. Observational study between June 1992 and December 2007. University tertiary referral center. Twenty-nine patients presenting deeply infiltrating endometriosis (DIE) with severe ureteral endometriosis. Severe ureteral endometriosis was defined as DIE lesions causing significant obstruction to the urinary flow with ureteral stenosis. Complete surgical exeresis of DIE lesions. Pre- and peroperative evaluation associated with histologic analysis. Intrinsic ureteral endometriosis was defined as presence of DIE lesions infiltrating the ureteral muscularis. In a series of 627 patients with histologic proved DIE, we observed 29 (4.6%) patients with severe ureteral endometriosis. Ureteral lesions (n = 34) were right sided in 7 (24.1%) patients, left sided in 17 (58.6%) patients, and bilateral in 5 (17.3%) patients. Eleven (37.9%) patients presented intrinsic lesions. Out of the 34 ureteral lesions 13 (38.2%) were intrinsic. In cases of radical ureteral surgery (n = 21 patients; n = 24 ureteral lesions) intrinsic ureteral DIE was observed in 52.4% (11 cases) of the patients and in 54.2% (13 cases) of the ureteral lesions. The prevalence of intrinsic ureteral endometriosis is underestimated. This result must be taken into account when specifying the surgical modalities for patients presenting with severe ureteral endometriosis.

Avaliação da classificação histológica da endometriose observada em implantes de mulheres portadoras de endometriose pélvica superficial e profunda

OBJETIVO: avaliar o padrão de diferenciação histológica em lesões de peritônio superficial e lesões de endometriose pélvica profunda (EPP), localizadas em ligamentos úteros-sacros, intestino (reto e sigmóide) e septo retovaginal. MÉTODOS: estudo prospectivo não randomizado, que incluiu 139 pacientes. Foram obtidas 234 biópsias (179 com EPP - Grupo Profundas - e 55 com endometriose superficial - Grupo Superficiais). Das 179 lesões de EPP (Grupo Profundas), 15 foram obtidas do septo retovaginal, 72 de nódulos do reto e sigmóide e 92 de ligamentos útero-sacrais. As biópsias foram classificadas em glandulares bem diferenciadas, glandulares indiferenciadas, glandulares mistas e estromal, com base em uma classificação morfológica específica. RESULTADOS: no Grupo Profundas, 33,5% das biópsias apresentaram padrão glandular indiferenciado e 46,9%, padrão glandular misto. No Grupo Superficiais, houve predominância do padrão glandular diferenciado (41,8%). Comparando especificamente as diferentes localizações das biópsias de lesão de EPP (Grupo Profundas), notou-se que o padrão glandular misto foi predominante nos nódulos intestinais (61,1%). CONCLUSÕES: foi possível concluir que há predomínio de endometriose glandular bem diferenciada na endometriose superficial, predomínio da doença mista e indiferenciada na EPP e, especificamente estudando a endometriose de reto e sigmóide, houve predomínio da endometriose glandular mista.

Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribution

To investigate whether knowledge of the anatomical distribution of histologically proven deeply infiltrating endometriosis (DIE) lesions contributes to understanding the pathogenesis. Observational study between June 1992 and December 2004 (retrospective study between 1992 and 2000; prospective study between 2001 and 2004). Continuous series of 426 patients suffering from pelvic pain who underwent complete surgical exeresis of DIE. DIE lesions were classified according to four different possibilities: (i) Firstly, DIE lesions were classified as located in the anterior or posterior pelvic compartment. (ii) Secondly, DIE were classified as left, median and right. (iii) Thirdly, DIE lesions were classified as pelvic or abdominal. (iv) Fourthly, DIE lesions that could present in a right and/or left location were classified as unilateral or bilateral. These 426 patients presented 759 histologically proven DIE lesions: bladder (48 lesions; 6.3%); uterosacral (USL) (400 lesions; 52.7%); vagina (123 lesions; 16.2%); ureter (16 lesions; 2.1%) and intestine (172, 22.7%). DIE lesions are significantly more often located in the pelvis (n=730 lesions) than in the abdomen (n=29 lesions) (P<0.0001). Pelvic DIE lesions are significantly more often located in the posterior compartment of the pelvis [682 DIE lesions (93.4%) versus 48 DIE lesions (6.6%); P<0.0001]. Pelvic DIE lesions are significantly more frequently located on the left side. For patients with unilateral pelvic DIE lesions, the anatomical distribution is significantly different in the three groups: left (172 lesions; 32.0%), median (284 lesions; 52.8%) and right (82 lesions; 15.2%) (P<0.0001). For patients with lateral lesions, left DIE lesions (172 lesions; 67.8%) were found significantly more frequently than right DIE lesions (82 lesions; 32.2%) (P<0.0001). A similar predisposition was observed when we included patients with bilateral pelvic DIE lesions (P=0.0031). The same significantly asymmetric distribution is observed for total (pelvic and abdominal) DIE lesions. Our results demonstrate that distribution of DIE lesions is asymmetric. It is possible that this is related to the anatomical difference between the left and right hemipelvis and to the flow of peritoneal fluid. These findings support the hypothesis that retrograde menstruation of regurgitated endometrial cells is implicated in the pathogenesis of DIE.

111: Deeply Infiltrating Endometriosis: Pathogenetic Implications of the Anatomical Distribution

Investigate if the knowledge of the anatomic distribution of histologically proved deeply infiltrating endometriosis (DIE) lesions contributes to understand pathogenesis. Observational study between June 1992 and December 2004 (retrospective study between 1992 and 2000; prospective study between 2001 and 2004). Continuous series of 426 patients suffering from pelvic pain who underwent complete surgical exeresis for DIE. DIE lesions were classified according to four different possibilities: (1) DIE lesions were classified as located in the anterior or posterior pelvic compartment. By definition anterior DIE was defined as bladder DIE and posterior DIE included the other pelvic DIE locations: uterosacral ligament (USL), vagina, ureter and intestine. (2) DIE were classified as left, median and right. By definition we classified as left DIE lesions the following (left USL, left ureter, sigmoid colon, descending colon), as median DIE lesions the following (bladder, vagina, rectum, rectosigmoid junction, transverse colon, small intestine, omentum) as right DIE lesions the following (right USL, right ureter, ascending colon, appendix, ileocecum junction). (3) DIE lesions were classified as pelvic or abdominal. We classified as abdominal DIE lesions the following: descending colon, transverse colon, ascending colon, appendix, ileocecum junction, small intestine, and omentum. All the other DIE locations (bladder, USL, vagina, ureter, rectum, rectosigmoid junction, sigmoid colon) were considered as pelvic DIE lesions; (4) DIE lesions that could presented right and/or left distribution (ureter, USL, …) were classified as unilateral or bilateral. These 426 patients presented 759 histologically proved DIE lesions: bladder (48 lesions; 6.3%); USL (400 lesions, 52.7%); vagina (123 lesions, 16.2%); ureter (16 lesions, 2.1%); intestine (172, 22.7%). Pelvic DIE lesions are significantly more often located in the posterior compartment of the pelvis (682 DIE lesions (93.4%) versus 48 DIE lesions (6.6%); p < 0.0001). Pelvic DIE lesions are significantly more frequently located on the left side. Patients with unilateral pelvic DIE lesions the anatomic distribution is significantly different in the three groups: left (172 lesions; 32.0%), median (284 lesions; 52.8%) and right (82 lesions; 15.2%) (p < 0.0001). Patients with lateral lesions, left DIE lesions (172 lesions; 67.8%) were found significantly more frequently than right DIE lesions (82 lesions; 32.2%) (p < 0.0001). A similar predisposition was observed when we included patients with bilateral pelvic DIE lesions (p = 0.0031). The same significantly asymetric distribution is observed for total (pelvic and abdominal) DIE lesions. Our results demonstrate that distribution of DIE lesions is asymmetric. It is possible that this is related to the anatomical difference of left and right hemipelvis and to flow of peritoneal fluid. These findings support the hypothesis that retrograde menstruation following by implantation of regurgitated endometrial cells is implicated in the pathogenesis of DIE.

Operative management of deeply infiltrating endometriosis: Results on pelvic pain symptoms according to a surgical classification

To assess the results of complete surgical excision for patients with painful functional symptoms in a context of histologically proven deeply infiltrating endometriosis (DIE). Retrospective analysis (Canadian Task Force classification II-2). University-affiliated hospital. One hundred thirty-two patients with pelvic pain symptoms and histologically proved DIE. The DIE lesions were classified according to surgical classification: uterosacral ligaments (USL), vagina, bladder, or intestine. Complete surgical excision of DIE lesions. A retrospective analysis was made of medical, operative, and pathologic reports as well as of questionnaires mailed to patients. Efficiency of surgical excision was assessed according to two methods: objective evaluation (numerical rating scale) and subjective evaluation (patients were asked to classify the improvement after surgery with one of the following: excellent, satisfactory, slight, or no improvement). For each symptom, the mean scores according to the numerical rating scale were significantly lower postoperatively. The difference between the preoperative and postoperative scores was 5.2 points +/- 3.6 for dysmenorrhea, 4.6 points +/- 3.1 for deep dyspareunia, 4.4 points +/- 3.7 for painful defecation during menstruation, 4.9 +/- 3.2 for lower urinary tract symptoms during menses, and 4.6 points +/- 3.4 for noncyclic chronic pelvic pain. Comparable results were observed for patients in each group according to the surgical classification of their DIE lesions: USL (n = 78 patients); vagina (n = 25 patients); bladder (n = 13 patients); and intestine (n = 16 patients). Subjective evaluation showed that the improvement was considered to be excellent in 40.2% of women (53 patients), satisfactory in 42.4% (56 patients), slight in 14.4% (19 patients), and nonexistent in 3.0% (4 patients). The patients' characteristics (i.e., age, gravidity, parity, body mass index, preoperative medical treatment, follow-up after surgery, number and location of DIE lesions, revised American Fertility Society stage, associated endometrioma) did not differ significantly according to whether the improvement was considered to be excellent (Group A: 53 patients) or not (Group B: 79 patients). Among the infertile patients (n = 78; 59.1%), there was no difference in pain improvement if the patient was pregnant or not in the 42 women who achieved pregnancy after the surgery. Complete surgical excision of DIE lesions results in a statistically significant reduction in painful functional symptoms. These results are observed whatever the main location of DIE lesions. The patients' preoperative characteristics have no significant influence on the result.

Surgical Management of Deeply Infiltrating Endometriosis: An Update

Deeply infiltrating endometriosis (DIE) manifests itself mainly in the form of pain, predominantly deep dyspareunia, and painful functional symptoms that are aggravated monthly during menstruation, with the semiology being directly correlated with the location of the lesions (bladder, rectum). A workup to assess the extent of the disease is necessary to establish an accurate map of the DIE lesions, which is the essential condition to perform complete exeresis. The treatment of first intention is surgical, because medical treatments are only palliative in the majority of cases. Successful treatment depends on achieving radical surgical exeresis. Analysis of the anatomical distribution of the DIE lesions allows a "surgical classification" to be proposed to standardize the modalities of surgical treatment. Further studies are needed to specify the place and modalities of medical treatments preoperatively and postoperatively.

Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification

Deeply infiltrating endometriosis (DIE) is recognized as a specific entity responsible for pain. The distribution of locations and their contribution to surgical management has not been previously studied. Medical, operative and pathological reports of 241 consecutive patients with histologically proven DIE were analysed. DIE lesions were classified as: (i). bladder, defined as infiltration of the muscularis propria; (ii). uterosacral ligaments (USL), as DIE of the USL alone; (iii). vagina, as DIE of the anterior rectovaginal pouch, the posterior vaginal fornix and the retroperitoneal area in between, and (iv). intestine, as DIE of the muscularis propria. A total of 241 patients presented 344 DIE lesions: USL (69.2%; 238); vaginal (14.5%; 50); bladder (6.4%; 22); intestinal (9.9%; 34). The proportion of isolated lesions differed significantly according to the DIE location: 83.2% (198) for USL DIE; 56.0% (28) for vaginal DIE; 59.0% (13) for bladder DIE; 29.4% (10) for intestinal DIE (P < 0.0001). The total number of DIE lesions varied significantly according to the location (P < 0.0001). In 39.1% of cases (9/23) intestinal lesions were multifocal. Only 20.6% (seven cases) of intestinal DIE were isolated and unifocal. Multifocality must be considered during the pre-operative work-up and surgical treatment of DIE. We propose a surgical classification based on the locations of DIE. Operative laparoscopy is efficient for bladder, USL and vaginal DIE. However, indications for laparotomy still exist, notably for bowel lesions.

Magnetic Resonance Imaging and Endometriosis: Deeply Infiltrating Endometriosis Does Not Originate from the Rectovaginal Septum

The goal of this study was to describe the magnetic resonance (MR) imaging signs of deeply infiltrating endometriosis (DIE) lesions and above all to find out if MR imaging can pinpoint the location of these lesions. We made a retrospective study of 8 patients presenting with histologically proven DIE lesions. The MR imaging results were compared with intraoperative findings. Nodules revealed on T1-weighted images as isointense to myometrium with hyperintense spots remained visible on the fat-suppressed spin echo images. When there was no rectal involvement, the T1- and T2-weighted images showed a hypointense transition area between the nodule and the rectum. The DIE nodules were in identical locations in every case, lying below the torus uterinum, level with the posterior vaginal fornix and the upper third of the posterior vaginal wall. Without exception, the DIE nodules were located above the upper edge of the rectovaginal septum, with the latter appearing fine and regular with no image of any nodule. Our MR imaging results suggest that DIE lesions do not originate from the rectovaginal septum.

Routine Clinical Examination Is Not Sufficient for Diagnosing and Locating Deeply Infiltrating Endometriosis

Study ObjectiveTo determine whether routine clinical examination is sufficient for the diagnosis and establishing the location of deeply infiltrating endometriosis (DIE). DesignRetrospective analysis (Canadian Task Force classification II-2). SettingUniversity-affiliated hospital. PatientsOne hundred sixty women with histologically proved deeply infiltrating endometriosis. Measurements and Main ResultsSpeculum examination allowed endometriotic lesions to be viewed in only 14.4% (23) of patients, and a classic, painful, spheric nodule was palpated in only 43.1% (69). Results of routine clinical examination varied significantly with location of DIE. Whereas a nodule was found in 80.0% (24) of patients with vaginal endometriosis, this rate dropped to only 35.3% (6) and 33.3% (34) in those with DIE of the digestive tract and uterosacral ligaments, respectively (p <0.0001). ConclusionHigh locations of DIE lesions at the level of uterosacral ligaments, bottom of the pouch of Douglas, and upper one-third of the posterior vaginal wall explain why results of routine clinical examination are so poor. The term “deep endometriosis infiltrating the rectovaginal septum” is generally incorrect in the true anatomic sense.